The disease can unfold in hours, sometimes with almost no warning signs.
Each year, a quiet crisis unfolds in emergency rooms across Spain and beyond: children arriving not with a diagnosis, but already deep in a metabolic emergency that could have been prevented. Up to four in ten children with type 1 diabetes debut with diabetic ketoacidosis — a life-threatening condition born of undetected insulin deficiency — revealing how a disease often announces itself not gradually, but as a sudden collapse. Medical voices like Dr. José Luis Portero are calling for a shift in how diabetes is monitored and understood, arguing that measuring ketone bodies alongside glucose could transform a recurring emergency into a manageable warning.
- Between 35 and 40 percent of children newly diagnosed with type 1 diabetes in Spain are already in ketoacidosis when they reach a doctor — meaning the disease is finding them before medicine does.
- DKA can develop within hours as the insulin-starved body burns fat and floods the bloodstream with toxic ketones, turning a silent metabolic shift into a critical, hospitalization-requiring emergency.
- For years, diabetes care focused almost exclusively on glucose monitoring, leaving ketone measurement as an overlooked afterthought — a gap that has quietly allowed preventable crises to multiply.
- A 2024 international consensus by the American Diabetes Association confirmed that DKA hospitalizations have risen significantly over the past decade, underscoring the urgency of early ketone detection and patient education.
- Dual glucose-and-ketone monitoring devices now offer patients the ability to catch metabolic breakdown at home before symptoms escalate, shifting the balance of power from the emergency room back to the individual.
- Portero frames late DKA diagnosis as a marker of inequality — children without access to education, monitoring tools, or attentive care are disproportionately the ones who arrive in crisis.
When a child is diagnosed with type 1 diabetes, there is a one-in-three — perhaps one-in-two-and-a-half — chance the diagnosis will not come in a clinic but in an emergency room, with the child already in diabetic ketoacidosis. This is the alarm Dr. José Luis Portero, medical director of Abbott Diabetes in Spain, has been raising with growing urgency. DKA occurs when the body, starved of insulin, abandons glucose for fuel and begins breaking down fat instead. The resulting ketone bodies accumulate in the blood, acidifying it to dangerous levels — sometimes within hours, sometimes with almost no warning.
Spain records eight to ten DKA cases per 100,000 people annually. But the numbers are most striking in children: between 35 and 40 percent of new pediatric type 1 diabetes diagnoses arrive already in ketoacidosis. For adolescents, the risk climbs higher still. These are not rare outliers — they are, in many cases, how the disease introduces itself.
Portero argues the crisis is largely preventable through early recognition. Glucose monitoring, long the cornerstone of diabetes management, tells only part of the story. The real early warning lies in ketone bodies — particularly beta-hydroxybutyrate — whose presence in the blood signals metabolic breakdown before symptoms become severe. For years, ketone monitoring was an afterthought in diabetes care, leaving patients and families without the knowledge or tools to act before a crisis took hold.
Education, Portero insists, is the missing piece. People with type 1 diabetes need to know when to measure ketones — during persistent high blood sugar, illness, or general malaise — and what to do when levels rise. The difference between catching this early and missing it can be the difference between home management and days in intensive care.
Technology is beginning to close this gap. Modern devices now allow rapid, accurate measurement of both glucose and ketones at home, enabling patients to detect the metabolic shift as it begins rather than after it has become an emergency. A 2024 international consensus published in Diabetes Care by the American Diabetes Association reinforced this direction, citing rising DKA hospitalizations over the past decade and calling for early ketone measurement and patient education as essential prevention tools. A Spanish study coordinated by Santiago Conde Barreiro confirmed that roughly one-third of children with type 1 diabetes present in ketoacidosis at diagnosis — not an edge case, but a common and preventable crisis.
Portero sees DKA as more than a medical emergency — it is a marker of inequality. Children diagnosed late, without access to education or monitoring, are the most likely to arrive in ketoacidosis. The answer lies not only in better technology but in awareness: training clinicians to recognize early signs of type 1 diabetes in children, teaching families what to watch for, and ensuring that symptoms like excessive thirst, fatigue, and weight loss are taken seriously immediately. Once ketoacidosis takes hold, the clock is already running.
When a child is diagnosed with type 1 diabetes, there is a one-in-three chance—perhaps as high as four in ten—that the diagnosis will arrive not in a doctor's office but in an emergency room, with the child already in diabetic ketoacidosis. This is the warning Dr. José Luis Portero, medical director of Abbott Diabetes in Spain, has been raising with increasing urgency. Diabetic ketoacidosis, or DKA, is what happens when the body has so little insulin that it cannot process glucose for energy. Instead, it turns to fat. The breakdown of fat produces ketone bodies—toxic compounds that accumulate in the bloodstream and acidify it to dangerous levels. The process can unfold in hours, sometimes with almost no warning signs.
In Spain alone, doctors see between eight and ten cases of DKA per 100,000 people each year—thousands of episodes annually. But the numbers are starker in children. When a young person receives a new diagnosis of type 1 diabetes, somewhere between 35 and 40 percent of them are already in ketoacidosis. For adolescents, the risk is even higher. These are not rare complications. They are, in many cases, the way the disease announces itself.
What makes this preventable, Portero argues, is early recognition. Most people with diabetes have been taught to monitor glucose—blood sugar levels—obsessively. But glucose tells only part of the story. The real warning sign is the presence of ketone bodies in the blood, particularly beta-hydroxybutyrate. Measuring ketones can catch metabolic breakdown before symptoms become severe, before the child ends up hospitalized. The problem is that for years, diabetes management focused almost entirely on glucose. Ketone monitoring was an afterthought, if it was considered at all. Patients did not know to watch for it. Doctors did not always recommend it. And so the disease progressed silently until it became an emergency.
Portero emphasizes that education is the missing piece. People with type 1 diabetes, and those with type 2 who depend on insulin, need to know when to measure ketones: when blood sugar is persistently high, when they have a fever or are vomiting, when they feel generally unwell. They need to understand that these are the moments when the body might be shifting into ketoacidosis. They need tools and clear instructions about what to do. The difference between catching this early and missing it can be the difference between managing it at home and spending days in intensive care.
Technology is beginning to change this. Modern devices now allow people to measure both glucose and ketone bodies quickly and accurately at home. This shifts power to the patient. Instead of waiting for symptoms or a crisis, someone with diabetes can now detect the metabolic shift as it begins. Recent research supports this approach. A 2024 international consensus statement published in Diabetes Care by the American Diabetes Association and other major scientific societies noted that hospital admissions for DKA have risen significantly over the past decade. The statement emphasizes early ketone measurement and patient education as critical tools for prevention. In Spain, a recent study coordinated by Santiago Conde Barreiro found that roughly one-third of children and adolescents with type 1 diabetes present with ketoacidosis at diagnosis—confirming that this is not a rare edge case but a common, preventable crisis.
Portero frames DKA as more than a medical emergency. It is also a marker of inequality. Children who are diagnosed late, who lack access to education about their disease, who cannot afford regular monitoring—these children are more likely to arrive at the hospital in ketoacidosis. The solution is not just better technology, though that helps. It is awareness. It is training doctors and nurses to recognize the early signs of type 1 diabetes in children. It is teaching families what to watch for. It is making sure that when a child shows the symptoms of diabetes—excessive thirst, frequent urination, fatigue, weight loss—someone takes it seriously immediately, rather than waiting. Because once ketoacidosis takes hold, the clock is running.
Citas Notables
Diabetic ketoacidosis is largely preventable if detected early. Lack of awareness and information means patients often fail to recognize warning signs.— Dr. José Luis Portero, medical director of Abbott Diabetes in Spain
Ketone measurement is a fundamental pillar of diabetes management, especially in high-risk situations, and serves as an early indicator of metabolic breakdown even before symptoms appear.— Dr. José Luis Portero
La Conversación del Hearth Otra perspectiva de la historia
Why does ketoacidosis happen so often at the moment of diagnosis? Shouldn't doctors catch type 1 diabetes before it gets that far?
Type 1 diabetes can develop very quickly, especially in children. The immune system attacks the insulin-producing cells, and sometimes the damage is nearly complete before anyone realizes what's happening. The child might seem fine one week and be in crisis the next. Many families don't recognize the early signs—they think it's just a growth spurt or a passing illness.
So the 35 to 40 percent figure—that's not a failure of medicine, it's just how the disease behaves?
It's both. The disease does move fast, but we're also not screening for it aggressively enough. And once symptoms appear, we're not always measuring ketones right away. We measure glucose, see it's high, and sometimes that's where we stop. We should be asking: what's causing this? Is the body breaking down fat? That's the question ketone measurement answers.
If someone is monitoring ketones at home, can they actually prevent ketoacidosis from becoming severe?
Yes. Early detection means you can act immediately—adjust insulin, drink fluids, seek help before the acidification becomes dangerous. It's the difference between a managed problem and a medical emergency. The technology exists now. The barrier is knowledge and access.
You mentioned this is a marker of inequality. What do you mean?
Children in wealthy areas with good healthcare access are more likely to be diagnosed before ketoacidosis develops. Children in underserved areas, or families without resources for regular monitoring, are more likely to arrive at the hospital in crisis. It's not random. It follows the same lines as everything else in healthcare.
What would change if every person with type 1 diabetes had a ketone monitor?
Everything. You'd catch problems hours or days before they become life-threatening. You'd reduce hospitalizations dramatically. You'd give families real control over the disease instead of just reacting to emergencies. But it requires education too—knowing when to use it, what the numbers mean, when to call a doctor.